Environment of Care

1. Environment of Care William A. Rutala, Ph.D., M.P.H., C.I.C. Director, Statewide Program for Infection Control and Epidemiology and Research Professor of Medicine, University of North Carolina at Chapel Hill, NC, USA Former Director, Hospital Epidemiology, Occupational Health and Safety, UNC Health Care, Chapel Hill, NC

2. Environment of Care • CBIC-14 questions. Will test knowledge of the following: • HVAC and construction • Water • Assess infection risks of design, construction and renovation • Evaluation and monitoring of environmental cleaning and disinfection practices • Evaluate environmental disinfection practices

3. Environment of Care • CBIC-14 questions. Will test knowledge of the following: • HVAC and construction • Water • Assess infection risks of design, construction and renovation • Evaluation and monitoring of environmental cleaning and disinfection practices • Evaluate environmental disinfection practices

6. Environmental Infection Control for Special Health Care Settings

7. SPECIAL HEALTHCARE SETTINGS(Airborne Infection Isolation-AII) • Planning new or renovating AII units • Directed airflow:exhaust air to the outside, away from air-intake and populated areas (IC) • Well-sealed room (IB) • Room-air pressure: Maintain continuous negative room with respect to corridor; monitor air pressure periodically (IB).; install self-closing doors (IC) • Room-air changes: Maintain at >12 per hour (IB)

8. Environmental Infection Control for Special Health Care Settings

9. Environmental Infection Control for Special Health Care Settings

12. Minimum Efficiency Reporting Value

13. Minimum Efficiency Reporting Value MERV 14 for OR

14. Heating, Ventilation and Air ConditioningMERV 8 (30-35% in 3-10u)

15. Heating, Ventilation and Air ConditioningMERV 11 (60-65% in 1-3u)

16. Heating, Ventilation and Air ConditioningMERV 14 (90-95% in 0.3-1u)

17. Heating, Ventilation and Air ConditioningHEPA (High Efficiency Particulate Air)

18. Heating, Ventilation and Air ConditioningActivated Carbon Filter-removes organic compounds and odors

19. Heating, Ventilation and Air ConditioningSupply Air to Hospital Patient Rooms

20. Heating, Ventilation and Air ConditioningExhaust Fans on Roof

21. Environment of Care • CBIC-14 questions. Will test knowledge of the following: • HVAC and construction (airborne fungal contaminants) • Water • Assess infection risks of design, construction and renovation • Evaluation and monitoring of environmental cleaning and disinfection practices • Evaluate environmental disinfection practices

22. AIRBORNE FUNGAL OUTBREAKS Requirements • Susceptible host • Reservoir • Source • Infecting dose inhaled (most dependent on concentration of fungi in the air)

23. MOST COMMON PATHOGENS ASSOCIATED WITH CONSTRUCTION OR RENOVATION OUTBREAKS • Aspergillus spp. (by far most important) • Zygomycetes • Other fungi • Miscellaneous

24. Review of Fungal OutbreaksKanamori, Rutala, Sickbert-Bennett, Weber. CID. 2015;61:433

25. NOSOCOMIAL ASPERGILLOSIS IN OUTBREAK SETTINIGSVonberg, Gastmeier. JHI 2006. 63:245 • 53 studies with 458 patients • 356 patients (78%) were lower respiratory tract • Aspergillus fumigatus (154) and A. flavus (101) • Underlying disease-hemotologic malignancies 299 (65%) • Overall fatality rate in these 299 patients (57.6%) • Construction or demolition probable/possible source-49%; virtually all outbreaks attributable to airborne source, usually construction • Patients at risk should not be exposed to Aspergillus

26. Review of Fungal OutbreaksKanamori, Rutala, Sickbert-Bennett, Weber. CID. 2015;61:433

27. Review of Fungal OutbreaksKanamori, Rutala, Sickbert-Bennett, Weber. CID. 2015;61:433

29. 8 cases of invasive fungal sinusitis (6 A. flavus, 1 A. fumigatus, 1 Rhizopus) and 5 deaths; release of fungal spores from soil reservoirs during construction; cultures of air and dust during the construction period grew Aspergillus . Lueg et al.1996

31. Aspergillus • Aspergillus spores are ubiquitous (soil, fruits, vegetables, dust, decaying organic matter) in the environment • Conidia may travel long distances as airborne particles and are inhaled by humans (several hundred spores each day) • In most healthy persons, spores are removed by innate defense mechanisms (macrophages) • Severely immunocompromised (IC) hosts (hematologic, solid organ transplant) a serious complication • Air is normally the route of fungal spore transmission

32. Medically-Important Mycotic AgentsAspergillus fumigatus

33. AIRBORNE FUNGAL OUTBREAKS

34. AIRBORNE FUNGAL OUTBREAKS • Shown to increase the amount of airborne fungal spores dramatically (and in consequence increases the risk of Aspergillus infection in susceptible patients) • Internal renovation/construction/excavation-construction is a never-ending phenomenon • Ceiling access • Contaminated or defective air supply • Minimal airborne concentration of Aspergillus necessary to cause infection in IC patients remains unknown

39. CONSTRUCTION OR RENOVATION1 • When planning construction, demolition, and renovation activities in and around the facility, assess whether patients at high-risk for aspergillosis are likely to be exposed to high ambient-air spore counts of Aspergillus spp., and if so develop a plan to prevent such exposure {lA} • During construction, demolition, or renovation activities construct impermeable barriers between patient-care and construction areas to prevent dust from entering the patient-care areas {lB] • Direct pedestrian traffic that come from construction areas away from patient-care areas to limit the opening and closing of doors or other barriers that might cause dust dispersion {lB} • Must participate at all levels of a construction project (CBIC) 1Tablan OC, et al. Guidelines for preventing health-care-associated pneumonia, 2003

40. CONSTRUCTION OR RENOVATION1 • Establish a multidisciplinary team that includes infection-control staff to coordinate demolition, construction and renovation {lB, lC} • Educate construction and healthcare staff in immunocompromised patient-care areas regarding airborne infection risks associated with construction and preventive measures {lB} • Incorporate mandatory adherence agreements for infection control into construction contracts {lC} • Establish and maintain surveillance for airborne environmental disease (e.g., aspergillosis) as appropriate during construction {lB} 1Guideline for environmental infection control in health-care facilities, 2003

41. CONSTRUCTION OR RENOVATION1 • Implement infection-control measures during construction, renovation, maintenance, demolition, and repair {lB, lC} • Before the project gets underway, perform an ICRA to define the scope of the project and need for barrier measures {lB, lC} • Determine if immunocompromised patients may be at risk for exposure and develop a contingency plan to prevent exposures • Implement infection-control measures for external demolition and construction {lB} • Determine if facility can operate on recirculated air; if feasible, seal off adjacent air intakes • If not feasible, check and replace low-efficiency filters as needed • Seal windows and reduce outside air intrusion 1Guideline for environmental infection control in health-care facilities, 2003

42. CONSTRUCTION OR RENOVATION1 • Implement infection-control measures during construction, renovation, maintenance, demolition, and repair {lB, lC} • Implement infection-control measure for internal construction {lB, IC} • Construct barriers to prevent dust from entering patient-care areas • Block and seal off return air vents (if needed) • Implement dust control measures; divert pedestrian traffic • Relocate patients adjacent to work zone (depending on their immune status) 1Guideline for environmental infection control in health-care facilities, 2003

43. CONSTRUCTION OR RENOVATION1 • Implement infection-control measures during construction, renovation, maintenance, demolition, and repair {lB, lC} • Perform engineering and work-site related infection control measures as needed for internal construction and renovations • Ensure proper operation of the air-handling system • Create and maintain negative pressure in work zones-CBIC • Monitor negative air flow inside of rigid barriers • Monitor barriers; repair gaps and breaks in barriers • Direct pedestrian traffic away from work zones • Provide designated travel routes for construction crew • Clean work zones daily • Clean and replace air filters 1Guideline for environmental infection control in health-care facilities, 2003

44. CONSTRUCTION OR RENOVATION1 • No recommendation is offered on routine microbiologic air sampling, before, during, or after construction {unresolved} • If a case of healthcare-acquired aspergillus airborne fungal infection occurs during construction, implement appropriate measures {lB} • If there is epidemiologic evidence of ongoing transmission of fungal disease, conduct an environmental assessment to determine and eliminate the source {lB} • If air-supply systems to high-risk areas are not optimal use portable, industrial-grade HEPA filters on temporary basis {ll}

45. INFECTION CONTROL RISK ASSESSMENT (ICRA) • ICRA is an multidisciplinary, organizational, documented process that after considering the facility’s patient population and type of construction project (non-invasive to major demolition): • Focuses on reduction of risk from infection • Acts through phases of facility planning, design, construction, renovation, facility maintenance and • Coordinates and weights knowledge about infection, infectious agents, type of construction project and care environment permitting the organization to anticipate potential impact

46. STEP 1:IDENTIFY TYPE OF CONSTRUCTION PROJECT http://www.premierinc.com/quality-safety/tools-services/safety/topics/construction/downloads/ICRA- MatrixColorRevised-091109.pdf

47. STEP 1:IDENTIFY TYPE OF CONSTRUCTION PROJECT

48. STEP 2:IDENTIFY PATIENT RISK

49. STEP 3:MATCH RISK GROUP WITH CONSTRUCTION TYPE

50. INFECTION CONTROL BY CLASS